In the US, criminal problem-solving courts, such as adult drug courts, veterans courts, mental health courts, driving under the influence courts, and juvenile courts, serve as an alternative to arrest/incarceration when a crime is related to a substance use disorder (SUD) or mental health disorder (National Association of Drug Court Professionals, 2015). Civil dependency courts, including general dependency courts, family dependency drug courts, and early childhood courts, seek to reunify parents with children whose custody was lost due to drug use (Center for Children and Family Futures and National Association of Drug Court Professionals, 2019). Criminal problem-solving courts and civil dependency courts mandate SUD treatment for participants with SUD, refer participants to treatment, and monitor treatment progress using an interdisciplinary team-based approach. Practices are generally similar across problem-solving courts, whether criminal or civil (Marlowe et al., 2016), except that criminal problem-solving courts can use jail time as sanctions to increase compliance with court requirements.
Problem-solving court teams typically include judges, court administrators (who oversee day-to-day operations of the court), court case managers, a treatment provider representative from a collaborating treatment agency, and other professionals. Voluntary national best practice standards recommend that problem-solving courts collaborate with only one or two behavioral health treatment agencies, with regular participation of treatment agency representatives (e.g., counselors) on the court team (National Association of Drug Court Professionals, 2015, 2018). Criminal problem-solving courts may include law enforcement, correction officials, and prosecutors on their team, while veterans courts typically include a veterans outreach specialist to facilitate referrals for treatment to the Veterans Health Administration (Andraka-Christou, 2017). While the court system employs judges, court administrators, and court case managers, other court team members may be used by other community agencies (e.g., probation officers by the department of corrections and the treatment provider representative by a community treatment agency).
Unfortunately, fewer than one in 20 justice-involved individuals with opioid use disorder (OUD) are referred to agonist medications for opioid use disorder (MOUD) (Krawczyk et al., 2017), which are the most effective treatments for OUD (Wakeman et al., 2020). Buprenorphine and methadone, both agonist medications, lower the rate of mortality by as much as 50% in people with OUD (Santo Jr. et al., 2021). Across criminal justice institutions, diversionary programs, like criminal problem-solving courts, are among the least likely to refer to agonist treatment. For example, in diversionary programs, only 2% of people with OUD are referred to agonist treatment, as compared to 3% from other courts, 5% from probation/parole, and 10% from prison (Krawczyk et al., 2017). It is unclear why problem-solving courts are less likely than other criminal justice institutions to refer individuals to agonist treatment, but low referrals are particularly concerning given that problem-solving courts are designed to facilitate SUD treatment and address underlying causes of drug-related behaviors (Krawczyk et al., 2017). Moreover, a recent Department of Justice ruling states that it is a violation of the American Disabilities Act to prohibit or limit the use of OUD treatment for individuals under court supervision (Department of Justice, 2022).
Some problem-solving courts have policies prohibiting the use of MOUD (Matusow et al., 2013), potentially explaining low MOUD utilization by court clients. For example, juvenile courts might have policies against referring adolescents to MOUD since the medications have not been approved for people under 18, even though studies demonstrate medication efficacy in adolescents (McCarty et al., 2021). Since courts typically operate autonomously, different courts in the same geographic area can have different policies and practices related to MOUD, unless restricted by state or federal law (Andraka-Christou et al., 2021). For example, federal law currently prohibits the receipt of grant funding by courts that ban MOUD utilization (U.S. Bureau of Justice Assistance, n.d.), and a few states have passed laws requiring courts to allow MOUD utilization (Andraka-Christou et al., 2022). Some national professional organizations, like the National Association of Drug Court Professionals, have passed voluntary best practice guidelines in an attempt to standardize treatment practices in problem-solving courts (National Association of Drug Court Professionals, 2018).
Several studies have also found negative attitudes toward agonist MOUD among court staff (Andraka-Christou, 2017; Andraka-Christou et al., 2019; Andraka-Christou & Atkins, 2020a, 2020b; Csete & Catania, 2013; Matusow et al., 2013). In contrast, court staff attitudes appear more favorable toward extended-release naltrexone (Andraka-Christou, 2017; Andraka-Christou et al., 2019; Andraka-Christou & Atkins, 2020a, 2020b; Csete & Catania, 2013; Matusow et al., 2013), an antagonist MOUD that lacks misuse potential but has lower efficacy in preventing overdose death (Wakeman et al., 2020). It is likely that court staff beliefs about MOUD influence court MOUD policies and referral practices (Andraka-Christou, 2017).
In addition to court policies, MOUD may be underutilized by court clients due to geographic disparities in the availability of MOUD. For example, even though most US counties now have at least one agonist MOUD provider (Andrilla & Patterson, 2021), such providers are less common in rural areas. Court clients in rural areas may also experience more transportation difficulties in accessing MOUD (Andrilla, Moore, Patterson, & Larson, 2019; Joudrey, Edelman, & Wang, 2019; Thomas, Van de Ven, & Mulrooney, 2020).
To develop more effective governmental policies and interventions for facilitating MOUD access among court participants, more information is needed about barriers to MOUD referrals in the court system, including how these barriers differ by court type and medication. For example, most studies to date on MOUD barriers in the court system have either not compared all three medications or have only focused on adult drug courts (Andraka-Christou, 2017; Csete & Catania, 2013; Fendrich & LeBel, 2019; Finigan et al., 2011; Gallagher et al., 2018; Gallagher et al., 2019; Hall et al., 2016; Krawczyk et al., 2017; Matusow et al., 2013; Robertson & Swartz, 2018; Substance Abuse and Mental Health Services Administration, 2014; Taxman & Bouffard, 2003), excluding other types of courts that regularly refer clients to SUD treatment (e.g., veterans courts, mental health courts, juvenile drug courts, and family dependency drug courts) (Matusow et al., 2013). Moreover, even though a lack of local MOUD providers is a known barrier to court referrals (Andraka-Christou, 2017; Csete & Catania, 2013; Matusow et al., 2013), prior studies have not disaggregated between the availability of any MOUD provider and availability of a MOUD provider whom court team members trust. Our study builds on prior work by examining court team members’ perceptions of the availability of trustworthy MOUD providers.
Research in the field of interorganizational relationships suggests that trust is one of several potential predictors of continuation and formation of interorganizational relationships (Nielsen, 2004). While several approaches to conceptualizing interorganizational trust exist, our research is guided by the general principle that interorganizational trust involves two key components: perception of a partner’s competence (e.g., technical skills, expertise, reliability) and integrity (e.g., motives, honesty, character) (Connelly et al., 2015). The role of trustworthiness in development and continuation of court-MOUD provider relationships remains poorly understood, although prior qualitative work suggests that court-MOUD provider relationships are unlikely to be established if court team members view local MOUD providers with distrust (Andraka-Christou, 2017). It is possible, for example, that court team members perceive local MOUD providers as lacking in competence or integrity, thereby hindering development of an interorganizational relationship.
It is also possible that court team members’ perceptions of the trustworthiness of an MOUD provider relate to the team members’ beliefs about the medication offered. For example, if a court team member believes methadone is inherently harmful, then they might also distrust methadone providers. To date, no study has examined the relationship between court team member perceptions of MOUD provider trustworthiness and team member beliefs about MOUD. Such information is necessary to inform the development of interventions facilitating relationships between court staff and MOUD providers, thereby potentially increasing referrals to MOUD treatment.
To help address these gaps, we used an online survey with an optional free-response text space to explore Florida criminal problem-solving court and civil dependency court team members’ perceptions of MOUD barriers. Specifically, we sought to (1) identify the relative frequency of different types of perceived barriers, comparing across medications, (2) explore the relationship between perceived MOUD barriers and beliefs about MOUD efficacy/safety, and (3) explore differences in perceived barriers by court type (i.e., criminal versus civil) and court role (e.g., judge, case manager). This research is part of a larger project examining MOUD barriers in the Florida court system (Andraka-Christou et al., 2020; Andraka-Christou et al., 2021; Andraka-Christou & Atkins, 2020a, 2020b).